S 3050 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ,BUILDING..ELECTRICAL 1 FSIT NO. 3050
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
J
IIUI IHNG.PROJECT IDEN'T'IFICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
So G&,56K 61610_ n -)-7-
C6NER'S NAM i- . 1 Pli^NF.(V//� CWIRAe:I(y'�'ti�MG: LIC NO:
ILLF/\ ./V NIC CONTROL#
CH ECT'/CNG IiliR:
LIC No ADDRESS: El
4 oS0
CONTACT: PH/ONE:y� BUILDING PERMIT INFO
G f ft)e� Co } �St��$(a� Ov(p3 ❑ Consultant Fees Paid by Applicant(initial) B >J G ELECT — 1
¢ MEC
LICENSED CONTRAC(ORIS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm mal 1 ner licensed ander pmvisiom of chapter 9(cmnmeneing JOB DESCRIPTION
O fOZ with Section 70001 of Division 3 of me Business and l'mfessions Code.a ylicense is RESIDENTIAL'
W O PERMIT ISSUANCE
= 1- in at
force rand ettem. 5 ❑SPDWI. ❑KITCHEN R[410DIii.
QUU License Ela. Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
t; W Date Comamor
A CHITECTS DEC(. A'I )N ❑MULTI-UNIT ❑STRUCTURAL
Z O w l untla stand my pl.nu.hull be usul u.pnblie remnlx PANELS MODIFICATION
O ZOO Ul"I'0200AMPS ❑INTPRIOR C:1 CHIMNEY REPAIR
F.�..�tat Licensed Profesvonal 211-10DOAMPS IMPROV(?MEN'(' )]SWIMMING POOLS
gbe2, OWNHR-BUILDER DECLARATION DVI:µI(N1IAMPS ❑IfAf1{REMODEIIREPAIR [-1 DEMOLITION
Q 1 hereby affirm that 1 am exempt from the Contractors License law for the
�3LLF following reason.ISectian 7(ULS,Business rand lknfnsionsCNc:Any city nr ummY SIGNS ELECTRICAL ❑OTHER
whch requires a pe 't to construct. Irtr ' pit e demolish,or reany d Imre
.�.�0 miA I I .. a I: y th pPli tf hpe it FI .'gad, mment SHIC1ALCIRCTIIUMISC.
so that he Jp n thep ,mit. III C I I L 1 (Chapter9
W�QO (Aonmenettg w'uh SeG 7000)of DtVl,.....3 l'da Bun ne,and lnl us'mts Lrvle)nr fEMI'.MI:TP.R OR POLI:IN S'L R IAL'
A,es Qo y thin he Is exempt 0aret'rnlo and the basis fit,the alleged exemption.Any violation of IiW HIAG/ADDIT[ON ❑DBMOIJ I ION
--N Section 7031S hynayapploorn for a permitsnhjec"the appllcanun a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more man five hundred dollars($500).
F Z YIMPROVEMENT
SSC will
LasimoemoftMpre,muteof my.limeaceswithwagwosalei(See.cam.1nsaion, SWIhIMINGPOOL E1.liCIRIC
F. and Jo tan work.rand Otesmnure is notimenJcd nn,Hcred forsale(Sw.]I44.Nusinns ❑DfIIIiR
6'3 rand Pmfesxirns Cale:The Commnces License lax'does not apply to an owner n( OUTLETS-SWRCHES-IIX'IV S
property who builds nr imprnve,<thereon,and who dnex such work himself nr through
his own employer,pn videe that such itnptoventems arc not immnded lir alk ed for NIIW RESIDENTIAL ELECTR SQ !�
sale.If,however,the huilding or intpmvemcnt isxold within ane ycunf campletimdtho SQ.FT.FLOOR AREA S/SQ.Pl'.
er-buildar will have the harden of proving than to did not build or iutmove far pur-
ryne of side.).
C]I,as nwn<r of the pmpeny,vat exclusively rnmraning with licensed commO a m TOTAL: p..r#----
nnstract the project(Sec.7144,Business and Professiron CoJc)The Contractors Li- - JV,O
Li-
came Law does not apply to an owner of proPeny who builds or improves thereon.and QTY PLUMBING PEqQD J PERMIT FEE 1
whocontacts hnimehprojuxwith aContarono0 iecroal pursued to the Contractors
License Law. PERMIT ISSUANCE
Ind exempt under See .B AN P C Iixlhi.reason
ACI'lilt-IIRAIN A.VENT'-Wn'IE?k(EA) VALUATION
Owner U
f WORKER'SCOMPEN DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perrpi,or jury one of the following JecFamtinns: r
Q I have and will maintain a Certificate of Consent to self-insure far Workers Compcn- DRAINS-FLODR,ROOP.ARF.A.CONDSTORIES TYPE CONSTROCI'ION
.radian,as provided for by Section 37M of the Labor Gyle,for the pxorarr ante of the AV/N
work for which this mann is issued. FIXTURES-PER TRAP
❑ 1 have and will nnllnmin Worker,Cmnpenaaloo Insurance,as cfairial by Semon
370lmfine Labor Code,linthe permarmanceol the work for which thi.,permi(Isi,u MS-IEA.SYS'T'EM-1 INC.4 OUTLETS DEC.GROUT' 4A
MyW r t 1Vilicy a Z4J G
am
Carzier� I'nllN Nn. GAS SI47IN EA US1B-WASrl:INT OJ
lE 'I'IPICA9 :OP EXEMPTION FROM W P.RS'
COMPENSATION INSURANCE GRIiANI%INUUS'IRL WAS'fli INTERCEPTOR
BUILDING DIVISION PEES
Oldswation raced not becomplemd i4hc permit E forone hundmddollars($100)
or les,.) GREASETRAP PLANCI IECK FE
(certify that in the performance of me work for which this permit is i,sued,lshall SEWER-SA �p
not employ any pao,on In any ma mor so o,to heuune witject to the Workers''Contpen- F.NIiRGY PEP
onionlaw,of C.1dialdn,Data WAIPRHENfI /VEN'I'l.
Z O Applicant ORnumr
y NOTICE TO APPLICANT IL ellennvking Ibis Cenifeme of Exemption,you xhnuld wYTER SYST ItEA1ING If
h ; become subject to the Workers Compensation provisions of the Labor Gale,you must SOILS P
forthwith comply with such provisions or this permit shall be deemed revoked. WAT17RSERV IAN 2 6 199
an
CONSTRUCTION LENDING AGENCY NEW RESIDO11 flAL('LMB. SQ.FR PAID
U O 1 fe Receipt#
I hereby aflinn Ilial IM1ere is a mn.wemm lending agency for the perfnnnance of
the work forwhich this Permit is issued(Sec YN7,Civ,C.)
QVfender,Name
lender's AJJre,s
>ia 1 certify that 1 have mad this application and,Inde that the above infnrnmtinn is IflJ11.UINC PEB
FTA correct.I agree to comply with all city and Cuumynrdinancesand state laws relating in QT-y. MECHANICAL PERMIT FEE
U z building construction,and hereby authorize representatives of this city to enter upm the SEAS MIC FEE
above mentioned property for impsermn pagan,. PERMIT ISSUANCP.
We)agree In save,indemnify and keep harmless the City of Cupertino against ELT:CfRI
I iubiliticu,judgmenrs,co,nvnd expenses ishichonry in any way accrue againa said City ALI'17R Olt ADD TO M ECH.
consequence of the grunting of this peanit. PLI1MIi1
APPLICAN9'I NDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR IIAN DLING U N I'1(1010,000 CFM)
SOURCE R4.XI IONS, ////��Q_1A �/p��/ MliCll .hEE
�_ 40JIM • / A I K I IANDLING ON I'r(OVER 10,000 CFM)
CO ll ION'[AX
Sig,TM97c.1A,plic.ff aC Date EXHAUSTHOOD(WA)UC ) HOUSING I'I'IGATIONFEI:
HAZARDOUS MA'TERIAIS DISCLOSURE
Wiil the applicant or latrans building�ccupunl store nr handle ha'earJnas material IIHAI'ING UNIT(TO I(11,10X1 IG U)
a,defined by the Cupenion Municipal Code.Chapter 9.12,and the Britain Intl Safety
Cale,Secfian 255920pp IIEA'I'ING UNIT(OVER❑XI.NXE BTU)
Vux
V 11N'I'I LAI ION PANS I NGLE:R HSID) PND Date Receipiq
r - Will the applicunt nr furore building nccupam use equipment m devices which
I mil hmsduu.v air contaminants as defined by the bay Arca Air Quality Management HOILIiR-COMP OHP OR 100.0NN(RTU)
EmmetI 'TOT L:
yes _./ I1p11.1iR-COAfP(OVI3R 100,000 BTU)0 �° AIR CONDITIONER
I have react me h:I.oremax materulx nyaircmeltts anger chapter n 95 of he tali- ISSUANCE DATE
I'nmia Heal1 A Sufety Gyle,Sections 25505,25539 In121534.1 umlerarnuI thus if the NEW RESIDENTIAL MPCH. SQ.Flt / '2'7-
building really huvaulcnnnl,Ihul it piny resh'vnsibiBlymnntly tho:ccupam
aft eay 11hiehorambOmetprior In lvnutmcenfa rtifcme (Gec'ulrNtp�
raphe vBcm
Date TOTAL] ISSUED BY. —t G
OFFICE